Chapter 3 ST-Elevation Myocardial Infarction4 CABG is benefi cial for patients with stable angina
who have 1- or 2-vessel coronary disease without
signifi cant proximal left anterior descending coro-
nary artery stenosis but with a large area of viable
myocardium and high-risk criteria on noninvasive
testing. (Level of Evidence: B)
5 CABG is recommended in patients with stable
angina who have 2-vessel disease with signifi cant
proximal left anterior descending coronary artery
stenosis and either ejection fraction less than 0.50 or
demonstrable ischemia on noninvasive testing.
(Level of Evidence: A)
- CABG surgery after STEMI and antiplatelet
agents
Class I
1 Aspirin should not be withheld before elective or
nonelective CABG after STEMI. (Level of Evidence:
C)
2 Aspirin (75 to 325 mg daily) should be prescribed
as soon as possible (within 24 hours) after CABG
unless contraindicated. (Level of Evidence: B)
3 In patients taking clopidogrel in whom elective
CABG is planned, the drug should be withheld for
5 to 7 days. (Level of Evidence: B)
J. Convalescence, discharge and post-MI care
See Figure 3.8.
- Risk stratifi cation at hospital discharge
a. Role of exercise testing
Class I
1 Exercise testing should be performed either in the
hospital or early after discharge in STEMI patients
not selected for cardiac catheterization and without
high-risk features to assess the presence and extent
of inducible ischemia. (Level of Evidence: B)
2 In patients with baseline abnormalities that com-
promise ECG interpretation, echocardiography or
myocardial perfusion imaging should be added to
standard exercise testing. (Level of Evidence: B)
Class IIb
Exercise testing might be considered before dis-
charge of patients recovering from STEMI to guide
the postdischarge exercise prescription or to evalu-
ate the functional signifi cance of a coronary lesion
previously identifi ed at angiography. (Level of Evi-
dence: C)
Class III
1 Exercise testing should not be performed within
2 to 3 days of STEMI in patients who have not
undergone successful reperfusion. (Level of Evidence:
C)
2 Exercise testing should not be performed to
evaluate patients with STEMI who have unstable
postinfarction angina, decompensated CHF, life-
threatening cardiac arrhythmias, noncardiac condi-
tions that severely limit their ability to exercise, or
other absolute contraindications to exercise testing.
(Level of Evidence: C)
3 Exercise testing should not be used for risk strati-
fi cation in patients with STEMI who have already
been selected for cardiac catheterization. (Level of
Evidence: C)b. Role of echocardiography
Class I
1 Echocardiography should be used in patients with
STEMI not undergoing LV angiography to assess
baseline LV function, especially if the patient is
hemodynamically unstable. (Level of Evidence: C)
2 Echocardiography should be used to evaluate
patients with inferior STEMI, clinical instability,
and clinical suspicion of RV infarction. (See ACC/
AHA Guidelines for Clinical Application of Echo-
cardiography.) (Level of Evidence: C)
3 Echocardiography should be used in patients with
STEMI to evaluate suspected complications, includ-
ing acute MR, cardiogenic shock, infarct expansion,
VSR, intracardiac thrombus, and pericardial effu-
sion. (Level of Evidence: C)
4 Stress echocardiography (or myocardial perfu-
sion imaging) should be used in patients with STEMI
for in-hospital or early post-discharge assessment
for inducible ischemia when baseline abnormalities
are expected to compromise ECG interpretation.
(Level of Evidence: C)Class IIa
1 Echocardiography is reasonable in patients with
STEMI to re-evaluate ventricular function during
recovery when results are used to guide therapy.
(Level of Evidence: C)
2 Dobutamine echocardiography (or myocardial
perfusion imaging) is reasonable in hemodynami-
cally and electrically stable patients four or more
days after STEMI to assess myocardial viability when